Improving patency of coronary conduits "valveless" veins and/or arterial grafts.

BACKGROUND: Veins used for coronary artery bypass operation have a well-documented limited long-term patency. Internal thoracic artery (ITA) grafts have shown exceptional "durability." Assumptions were made that other arterial conduits have similar characteristics. AIM OF THE STUDY: The purpose of this article is to compare different conduits long-term patency including saphenous veins to other available arterial conduits: inferior epigastric artery (IE), right gastroepiploic artery (RGEA), and radial artery (RA). METHODS: Recent studies have shown that radial artery bypasses have lower patency rate than saphenous veins. Flow patterns, physiological flow characteristics are reviewed including native vessel disease and area of myocardium supplied. In the case of venous bypasses, the primary culprit of failure seemed to be the quality of the vein itself and the reverse venous valves in the conduit resulting in: (a) trapping-hypertension, (b) thrombosis, (c) turbulence, (d) intimal damage, (e) mismatching in size. RESULTS: Clinical follow-up of our patients up to 8 to 11 years (average 8.9 years) have proved the superior characteristics of the so-called "good veins." In a retrospective study of 436 patients sequential, valveless veins patency was 88.6% versus 72% of reversed valvular segments (p < 0.01). Patients' survival seemed to be significantly improved if these veins were combined with ITA grafts. Patients' survival with one valveless limb HS + ITA was 78% versus HS + SV 52% (p < or = 0.0017) and HS + ITA versus HS + ITA + SV (p < 0.0057). CONCLUSION: Selective decision-making of the surgeon at the time of the operation is required to choose the best conduit to be able to perform the best operation with the best long-term result.

Geometric modeling of functional trileaflet aortic valves: development and clinical applications.

The dimensions of the aortic valve components condition its ability to prevent blood from flowing back into the heart. While the theoretical parameters for best trileaflet valve performance have already been established, an effective approach to describe other less optimal, but functional models has been lacking. Our goal was to establish a method to determine by how much the dimensions of the aortic valve components can vary while still maintaining proper function. Measurements were made on silicone rubber casts of human aortic valves to document the range of dimensional variability encountered in normal adult valves. Analytical equations were written to describe a fully three-dimensional geometric model of a trileaflet valve in both the open and closed positions. A complete set of analytical, numerical and graphical tools was developed to explore a range of component dimensions within functional aortic valves. A list of geometric guidelines was established to ensure safe operation of the valve during the cardiac cycle, with practical safety margins. The geometry-based model presented here allows determining quickly if a certain set of valve component dimensions results in a functional valve. This is of great interest to designers of new prosthetic heart valve models, as well as to surgeons involved in valve-sparing surgery.

Quantitative approach to aortic valve-sparing surgery.

Our goal was to understand why it is difficult to achieve reliable valve competence after aortic valve-sparing surgery, and to propose quantitative data aimed at improving the outcome of the procedure. Valve-sparing procedures were performed in patients with dilated aortic roots and aortic regurgitation, and reproduced in physical models to explore what should be the restored dimensions of the aortic root and leaflets for valve sparing to be successful. In parallel, a three-dimensional geometric model of the aortic valve was tested to evaluate its capability to predict the annulus diameter, sinotubular junction diameter, valve height, and leaflet free-edge length and height in competent spared valves. Valve sparing resulted in more or less severe residual regurgitation in all the patients considered. Successful valve-sparing was achieved in vitro by making further changes to the annulus diameter, the leaflet free-edge length and/or graft size. The changes needed were effectively predicted by the geometric model. Tabulated valve dimensions allowing restoration of competence were generated for convenient use by surgeons. A quantitative approach to aortic valve sparing is proposed, putting emphasis on the functional characteristics of the restored valve geometry.

Aortic root dilatation may alter the dimensions of the valve leaflets.

OBJECTIVE: Valve-sparing surgery can be used in patients with dilated aortic roots and aortic insufficiency (AI) but has not become a common practice, in part because the spared valve may be incompetent. Our goal was to study how the dimensions of the aortic root and leaflets have changed in such patients. METHODS: Fourteen patients with dilated aortic root and AI were examined by transesophageal echocardiography. The annulus diameter, sinotubular junction (STJ) diameter, sinus height, leaflet free-edge length, and leaflet height were measured. Correlations among these dimensions and with the AI grades were explored. Measurements were also made in 19 normal human aortic valves from silicone molds. RESULTS: There was no evident change in the average diameter of the annulus between the normal valves and those in the dilated aortic roots. The STJ diameter was obviously increased in the dilated aortic roots; the aortic sinuses also appeared to be taller and the leaflets larger than normal. The leaflet free-edge length, the leaflet height, and the sinus height were found to increase with the dilated STJ diameter. The degree of AI was not found to correlate well with any of the dimensions measured. CONCLUSIONS: The dimensions of the leaflets may change parallel to aortic root dilatation with AI. Therefore, during valve sparing, it may be necessary to correct both the dilatation of the root and the leaflet free-edge length to achieve a competent valve.

Are there surgical implications to aortic root motion?

BACKGROUND AND AIM OF THE STUDY: By increasing the longitudinal stress in the ascending aorta, downward movement of the aortic root might promote the proximal transverse tears seen in aortic dissections. The study aim was to evaluate the influence of five common cardiac conditions on the magnitude of aortic root displacement in cardiac patients. METHODS: Aortic root contrast injections were analyzed in 90 patients (mean age 68 years) to measure downward motion of the root perpendicular to the plane of the sinotubular junction (STJ). RESULTS: Displacement of the aortic root ranged from 0 to 14 mm (mean 4.8 mm). Patients with aortic insufficiency (AI) showed increased aortic root movement (7.3 versus 4.3 mm, p = 0.003), whereas those with left ventricular hypokinesis (3.7 versus 5.5 mm, p = 0.014) or with myocardial hypertrophy (3.8 versus 5.1 mm, p = 0.073) exhibited reduced downward movement. These variables were independent, and correlated with the magnitude of aortic root motion. A stress analysis of the aortic root, arch and branches of the arch determined that the longitudinal stress approximately 2 cm above the STJ, in the outer curve of the aorta, was increased by 32% in patients with AI compared to patients without AI. CONCLUSION: Patients with cardiac conditions associated with increased aortic root motion such as AI may be at greater risk of aortic dissection because of increased longitudinal stress in the ascending aorta. Therefore, AI should be used as an indicator and aortic root displacement monitored to prevent the risk of aortic dissection.

Increased aortic wall stress in aortic insufficiency: clinical data and computer model.

OBJECTIVE: The study was aimed at determining which cardiac pathologies are associated with increased longitudinal stress in the aorta and therefore may be responsible for the intimal transverse tears seen in aortic dissections. METHODS: Aortic root contrast injections were analyzed in 90 cardiac patients to measure the downward motion of the annulus during a cardiac cycle. A finite element model of the pressurized aortic root, arch and supra-aortic vessels was created to assess the influence of the aortic root motion on the aortic wall stress. RESULTS: The axial displacement of the aortic root ranged from 0 to 14 mm. A multivariate analysis showed that aortic insufficiency (AI) grade, hypokinesis of the left ventricle (HKI), and myocardial hypertrophy (HTR) were 3 independent variables which correlated with the axial displacement of the aortic root (DISP), such that ARM (mm)=5.379 (P<0.0001) +1.186 x AI grade (P=0.0016) - 1.611 x HKI (P=0.0078) - 1.399 x HTR (P=0.0355) with R2=0.23. The major finding of the stress analysis was that in the ascending aorta, at approximately 2 cm above the sino-tubular junction, the longitudinal stress due to aortic root motion was 32% higher in patients with AI than in patients without AI, thereby increasing the risk of transverse intimal rupture. CONCLUSIONS: Cardiac patients with AI are likely to experience enhanced longitudinal stress in the ascending aorta due to increased aortic root motion. Thus, these patients should be targeted and their aortic root movement monitored because it may be an important risk factor for aortic dissection.

Does post-stenotic dilatation enhance collateral flow?

Our goal was to investigate whether post-stenotic dilatation (PSD) enhances collateral blood flow. In vitro experiments and computer modeling analysis were used to study the flow through stenotic segments and through collateral channels in the presence and absence of PSD. Pulsatile blood flow was provided by a left heart simulator primed with glycerol or normal saline. Pressure gradients across the stenosis were measured at different "cardiac" outputs. Computer models were constructed to simulate the experiments. Flow patterns and pressure drop across the stenosis were determined for a steady flow of 3 L/min. We observed that PSD was associated with a larger pressure drop across the stenosis than the absence of PSD when the flow was occurring through the stenosis only. There was, however, no difference in the pressure drop between the two geometries when the flow was occurring through both the stenotic orifice and the collateral channels when saline solution was used, but a small pressure difference prevailed for glycerol. At all different geometries there was considerable turbulence at PSD, and PSD geometry was found to be either at a disadvantage or at no advantage when compared to the tapered geometry for the total flow past the stenosis. The PSD geometry, however, enhanced the flow through the collateral while the flow through the orifice decreased concomitantly, resulting in no net increase in the total flow. This was true for any proportion of the total flow going through the collateral channels. For the total flow past the stenosis, PSD does not offer a benefit over tapered geometry.

Morphological changes of the aortic valve leaflets in non-compliant aortic roots: in-vivo experiments.

BACKGROUND AND AIM OF THE STUDY: Age-related loss of elasticity of the naturally compliant aortic root disrupts the coordinated function of the valve leaflets. Morphological changes that developed over time in the aortic valve leaflets of non-compliant aortic roots were studied. METHODS: Stiffening of the aortic roots was achieved in vivo by applying Super Glue around the sinus of Valsalva in 27 New Zealand White rabbits. In nine animals, glue was applied only partially, and eight untreated rabbits served as controls. Histological evaluation of the aortic valves was performed at 8-11 months after surgery, and included immunohistochemistry and confocal microscopy with quantitative tissue assessment. Levels of collagen I, as a main component of fibrosis, and matrix metalloproteinases (MMP)-1 and MMP-9 and angiotensin-converting enzyme (ACE), as regulators of fibrosis, were analyzed. The morphological structure of the aortic valve leaflets was studied, and the length, thickness and area of leaflets were measured. RESULTS: Leaflects in all groups were found to be composed of a continuous layer of collagen fibers at the mural side, and loose connective tissue containing fibroblasts and few capillaries on the aortic luminal aspect. In stiffened aortic roots, the length and area of the leaflets were increased. The area occupied by collagen was elevated in non-compliant aortic root leaflets, but collagen fluorescence intensity was decreased, indicating less densely packed collagen fibers. Degradation and synthesis of collagen as reflected by MMP-1, MMP-9 and ACE levels was up-regulated. CONCLUSION: Loss of compliance in aortic roots leads to elongation of the leaflets which, combined with a decrease in collagen density, may render leaflets more susceptible to mechanical stress. In time, this may promote the development of degenerative changes in the aortic valve.

Role of aortic root motion in the pathogenesis of aortic dissection.

BACKGROUND: The downward movement of the aortic root during the cardiac cycle may be responsible for producing the circumferential tear observed in aortic dissections. METHODS AND RESULTS: Contrast injections were investigated in 40 cardiac patients, and a finite element model of the aortic root, arch, and branches of the arch was built to assess the influence of aortic root displacement and pressure on the aortic wall stress. The axial displacement of the aortic root ranged from 0 to 14 mm. It was increased in patients with aortic insufficiency (22+/-13% of the sino-tubular junction diameter versus 12+/-9%) and reduced in patients with hypokinesis of the left ventricle (10+/-9% of sino-tubular junction versus 17+/-12%). The largest stress increase due to aortic root displacement was found approximately 2 cm above the sino-tubular junction, where the longitudinal stress increased by 50% to 0.32 Nmm(-2) when 8.9-mm axial displacement was applied in addition to 120-mm Hg luminal pressure. A similar result was observed when the pressure load was increased to 180 mm Hg without axial displacement. CONCLUSIONS: Both aortic root displacement and hypertension significantly increase the longitudinal stress in the ascending aorta. For patients with hypertension who are at risk of dissection, aortic root movement may be monitored as an important risk factor.

The congenitally bicuspid aortic valve: how does it function? Why does it fail?

BACKGROUND: The study was intended to investigate the reason why congenitally bicuspid valves (CBAVs), which may function hemodynamically and clinically well, have a high early failure rate. METHODS: Observations were made on cryopreserved, then thawed human aortic roots containing CBAVs. Valvular function was studied in the left heart simulator using conventional and 500-frames/second cinematography, intravascular ultrasound, by preparation of silicone molds, and by computerized digital modeling. RESULTS: The function of the clinically "normal" CBAVs is characterized by (a). excessive folding and creasing, which (unlike in the trileaflet valve) persist throughout the cardiac cycle; (b). extended areas of leaflet contact; (c). significant morphologic stenosis; and (d). asymmetrical flow patterns and turbulence. CONCLUSIONS: The above features subject the CBAV to abnormally high stresses and may lead to early thickening and eventually calcification and stenosis. The abnormal flow patterns also predilect for dilatation and dissection of the ascending aorta.

Cause of degenerative disease of the trileaflet aortic valve: review of subject and presentation of a new theory.

Risk factors for both atherosclerotic aortic wall disease and degenerative disease of the trileaflet aortic valve are very similar if not identical. This correlation grows even stronger as the person advances in years. Because of this, it is the prevailing view that sclerosis of the trileaflet aortic valve, unless previously affected by septic or rheumatic endocarditis, is a disease similar in origin to sclerosis of the aortic wall, ie, degenerative aortic valve disease is arteriosclerosis of the aortic valve. Our studies challenge these views. The aortic valve is a functional assembly composed of the three cusps, corresponding sinuses, and the sino-tubular junction, characterized not only by morphologic features but also by its functional properties, which together create an environment that is optimal for distribution of diastolic pressure load and assures proper and timely valve opening and closure. Our more recent experiments also demonstrate that loss of aortic wall compliance at the level of the sinuses leads to significant stress-overload on the aortic leaflets and it is likely to start a chain of events, which begins with minor changes in their microstructure, then continues in more evident sclerosis, and finally ends in gross distortion or calcification of the cusps. The loss of the "pull-and-release" process may also play a part in disintegration of bioprosthetic valves and in degeneration of native aortic valves encased in noncompliant prostheses.